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21st June 2023
Patients are being urged not to suddenly stop taking antidepressants after seeing headlines warning that people may be taking them for too long.
A BBC Panorama programme reported NHS figures that about two million people have been taking them for five years.
The investigation also raised questions about evidence for their long-term use and that this may increase the risk of withdrawal symptoms when people try to stop.
It follows a study last year in which researchers said patients should not be told that depression is a chemical imbalance in the brain because there was ‘no convincing evidence’ that depression is caused by serotonin abnormalities.
The team at University College London (UCL) said although antidepressants can work for patients, it is not clear how they work, and patients needed to be aware of that when making decisions about treatment.
But the debate came to the fore once more this week when a group of researchers wrote a piece in the journal Molecular Psychiatry warning that the conclusion in the UCL research had been overstated and there had been selective reporting of data.
Professor Tony Kendrick, professor of primary care at the University of Southampton, said he had spoken to Panorama about the soon-to-be-published results from the REDUCE trial of a programme of support for those coming off long term antidepressants, but it had not been included.
‘The preliminary findings have shown a good proportion of people can come off long-term antidepressants with tapering advice provided by their GPs, and that internet and telephone support from a psychological wellbeing practitioner may help protect them from depressive and withdrawal symptoms,’ he said.
More detail from the three-year study involving 131 practices and 330 patients will be reported soon but it was shown to be cost effective, he added.
Responding to the Panorama investigation, RCGP chair Professor Kamila Hawthorne said when prescribed appropriately, evidence shows that antidepressants can be an effective treatment for many patients suffering from mental health conditions such as depression and anxiety.
Where alternative options may be helpful to medication, access can be patchy and slow, she noted.
But, she added: ‘Wherever possible we don’t want patients to have to rely on medication long term, and most patients don’t want that either.
‘If it is appropriate for patients to continue with antidepressants, we will schedule ongoing medication reviews to explore whether there are opportunities to reduce dosages, or stop taking medication altogether.
‘If a patient wants to stop taking antidepressants or reduce their dose, it is important that they speak to their GP, or prescribing clinician, in the first instance, and not simply stop taking their medication, as this could be very uncomfortable, and potentially dangerous, due to withdrawal effects.’
The Royal College of Psychiatrists said use of antidepressants should be carefully monitored and reviewed regularly.
‘Most people will be able to stop taking antidepressants without significant difficulty by reducing the dose (known as ‘tapering’) over a few weeks or months.
‘Some people can experience withdrawal symptoms that last longer and may be more severe, particularly when the medication is stopped suddenly.’
The College said NICE guidance in recent years has reflected the body of evidence on withdrawal symptoms with a greater focus on how to manage that safely.
‘Ultimately, the use of antidepressants, should always be a shared decision between a patient and their doctor based on clinical need and the preferences of the patient.
‘We would advise all those thinking of stopping their antidepressants to talk to their doctor first, as these medications should not be stopped abruptly.’
11th May 2023
There is insufficient evidence to justify the use of most antidepressants that are currently prescribed for chronic pain, Cochrane reviewers have concluded.
A team from Newcastle and Southampton universities analysed 175 trials of almost 30,000 patients and found only duloxetine was associated with reliable evidence of pain relief at least in the short-term for fibromyalgia, musculoskeletal, and neuropathic pain conditions.
There was no evidence of benefit for amitriptyline, which the researchers said was the most commonly prescribed antidepressant for pain management worldwide.
Other drugs for which there was a lack of evidence in chronic pain were fluoxetine, citalopram, paroxetine, and sertraline, the review found.
And data on long-term safety of antidepressants in this context was particularly poor, the researchers noted, saying they were ‘uncertain’ about unwanted effects and this needs to be studied further.
But the team stressed that ‘adopting a person-centred approach is critical’ concluding: ‘Pain is a very individual experience and certain medications may work for people even while the research evidence is inconclusive or unavailable.
‘Future studies should last longer and focus on unwanted effects of antidepressants.’
A guideline last year from NICE on medicines associated with withdrawal or dependence recommended regular reviews for patients on antidepressants and drugs for chronic pain.
Co-author Dr Gavin Stewart a statistician at Newcastle University, said: ‘Our study is one of the biggest of its kind and demonstrates the need for large-scale studies in this field.
‘Data is often complex and nuanced but the evidence underpinning the use of these treatments is not conclusive for most of the antidepressants we studied and, therefore, current treatment options are hard to justify.’
Study lead Professor Tamar Pincus, who researches the psychological aspects of chronic pain at the University of Southampton, said: ‘Chronic pain is a problem for millions who are prescribed antidepressants without sufficient scientific proof they help, nor an understanding of the long-term impact on health.
‘Our review found no reliable evidence for the long-term efficacy of any antidepressant, and no reliable evidence for their safety for chronic pain at any point.
‘Though we did find that duloxetine provided short-term pain relief for patients we studied, we remain concerned about its possible long-term harm due to the gaps in current evidence.’
But she stressed the findings did not mean people should stop taking prescribed medication without consulting their GP.
Dr Cathy Stannard, clinical lead on the NICE Guideline for Chronic Pain said: ‘This well conducted review adds to the substantial evidence we now have that shows that the use of medicines to treat long term pain is disappointing.’
She added that the conclusion that the best evidence is for duloxetine is unsurprising because trials for this newer drug were more rigorously done.
‘The study rightly highlights the significant adverse effect that chronic pain has on the quality of life for the people living with it. It’s equally important to emphasise the many social and psychological influences on the pain experience.
‘There is good evidence that for people with pain, compassionate and consistent relationships with clinicians remain the foundations of successful care.’